Burn Injury Model of Care PDF

Injury & Trauma
Health Network
Burn Injury
Model of Care
Professor Fiona Wood

Clinical Lead
4 May 2009
© Department of Health, State of Western Australia (2009).
Copyright to this material produced by the Western Australian Department of Health
belongs to the State of Western Australia, under the provisions of the Copyright Act
1968 (C’wth Australia). Apart from any fair dealing for personal, academic, research
or non-commercial use, no part may be reproduced without written permission of the
Health Networks Branch, Western Australian Department of Health. The Department
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Suggested Citation
Department of Health, Western Australia. Burn Injury Model of Care. Perth:
Health Networks Branch, Department of Health, Western Australia; 2009.
Important Disclaimer:
All information and content in this Material is provided in good faith by the WA
Department of Health, and is based on sources believed to be reliable and accurate
at the time of development. The State of Western Australia, the WA Department of
Health and their respective officers, employees and agents, do not accept legal
liability or responsibility for the Material, or any consequences arising from its use.
2
Table of Contents
Acknowledgements.................................................................................................. 6
1. Executive Summary .......................................................................................... 7
2. Recommendations ............................................................................................ 9
3. Definition of Burn Injury ................................................................................. 12
4. Principles ......................................................................................................... 13
5. Overview of Burn Injury .................................................................................. 14
5.1 International ........................................................................................... 14
5.2 National .................................................................................................. 14
5.3 Western Australia .................................................................................. 15
5.3.1 Trends by gender ................................................................................ 15
5.3.2 Trends by age ..................................................................................... 16
5.3.3 Aboriginal population .......................................................................... 17
5.3.4 Rural and remote population............................................................... 19
5.3.5 Types of Burn Injury............................................................................ 20
6 Causes of Burn Injury ..................................................................................... 22
6.1 Associated risk factors ......................................................................... 22
6.2 Target groups......................................................................................... 23
7. Proposed Model of Care for Burn Injury ....................................................... 24
7.1 Prevention .............................................................................................. 24
7.1.1 Current prevention strategies in WA ................................................... 24
7.1.2 Proposed strategies for injury prevention ........................................... 28
7.2 Burn Injury management ...................................................................... 32
7.2.1 Pre hospital care/immediate care ....................................................... 32
7.2.2 Transport/transfer ............................................................................... 33
7.3 Care considerations .............................................................................. 36
7.3.1 Assessment......................................................................................... 36
7.3.2 Minor burn ........................................................................................... 36
7.3.3 Moderate burn..................................................................................... 37
7.3.4 Severe burn......................................................................................... 37
7.3.5 Special considerations for all burn patients ........................................ 40
7.3.6 Psychosocial and mental health care ................................................. 45
7.3.7 Ambulatory Care Strategies................................................................ 48
7.4 Workforce education and training........................................................ 49
7.4.1 Pre tertiary hospital care ..................................................................... 50
7.4.2 Specialist tertiary services education and training.............................. 51
7.4.3 Mass casualty care and stabilisation .................................................. 52
7.5 Outcomes ............................................................................................... 53
7.5.1 Clinical Review.................................................................................... 53
7.5.2 Quality Improvement and Research ................................................... 53
7.5.3 Information and Care Management System ....................................... 54
3
Glossary .................................................................................................................. 55
Appendices ............................................................................................................. 56
Appendix A: Aboriginal health impact statement ....................................... 56
References .............................................................................................................. 57
4
Index of Tables
Table 1. Proportions of hospitalisations for Burn Injury by cause, non
Aboriginal and Aboriginal in Western Australia 2004/2005-
2006/2007...............................................................................................18
Table 2. Injury related fire burns and scalds by age and cause WA 2004/05-
2006/07...................................................................................................21
Index of Figures
Figure 1. WA Burn Injury definition ........................................................................12
Figure 2. Triangle of Care......................................................................................12
Figure 3. Hospital admission rates with a principal diagnosis of injury and a
primary cause of fire, burns and scalds, by sex, WA, 1988/89-
2006/079 .................................................................................................16
Figure 4. Hospital separations with a principal diagnosis of injury and a primary
cause of fire, burns and scalds, by sex, WA, 2004/05-2006/079 .............17
Figure 5. Age standardised rate, all burns (a) by Aboriginal status, WA,
1999/00–2006/07 .................................................................................18
Figure 6. Age-standardised hospital separations with a principal diagnosis of
injury and a primary cause of fire, burns and scalds, by region, WA,
2004/05-2006/079 ...................................................................................19
injury and a primary cause of fire, burns and scalds, by health region,
WA, 2004/05-2006/079 ...........................................................................20
Figure 8. Pathway for access to Burn Injury services in WA..................................35
5
Acknowledgements
The Model of Care for Burn Injury would not be possible without the cooperation and
help of distinctive individuals. Dr Simon Towler (Chief Medical Officer) would like to
acknowledge the contribution made by the following individuals:
WA Adult and Paediatric Burn Services representatives: Professor Fiona Wood,
Mrs Joy Fong, Ms Tania McWilliams, Dr Suzanne Rea and Mr Dale Edgar and
Ms Alwena Willis.
The Injury Prevention Working Group: Chair - Deborah Costello (CEO Injury
Control Council of WA); Deputy Chair Gary Kirby (WA Drug & Alcohol Office);
Sue Wicks (CEO Kidsafe WA); Janelle Leiper (WA Country Health Service
South West Health Region); and Greg Tate(Programme Manager, Royal Life
Saving Society WA), Sylvia Griffiths (DoHWA Population Health Division) and
Ms Chris Costa (Inaugural Chair)
Health Network Branch representatives: Karina Moore, Jeri Sein and Rachael
Biddulph, Marea Gent.
6
1. Executive Summary
The Injury and Trauma Health Network has identified burns as a major cause of
injury in Western Australia (WA); hence, the need to develop an overarching WA
Model of Care and, associated guidelines that include prevention, treatment,
management and care of Burn Injury.
In general, people who experience Burn Injury in WA are well supported by a range
of services that are delivered within a multi-disciplinary team approach. There are a
number of constraints that impact upon service delivery including, the size of
Western Australia’s geographic area, workforce education and training, and specialist
services distribution. Currently, the centralised Burn Injury services make good use of
innovations in service delivery such as Ambulatory Care (Burn Early Discharge
Programme) and e-health with some link to WoundsWest to overcome the
constraints. There are however many more opportunities to progress toward a more
cohesive, inclusive and equitable burn care pathway; a pathway that is built around
patient needs and brings together the experience of the carer, supported by facilities
that meet the patient’s needs. Burn Injury prevention initiatives also require further
development.
Although largely preventable, Burns Injuries are common and can be effectively
treated with appropriate and timely intervention. Severe Burn Injury is fortunately far
less frequent but the devastating outcome can be reduced dramatically when the
right care is provided at the right time, in the right place, by the right team. The
‘triangle of care’ (Figure 2) is applied to assist in determining if in fact the time, place
and team present are right for the patient at the point of contact.
Further to this an accurate definition of the Burn Injury, access to safe and reliable
services supported by well trained staff who rigorously evaluate the care they give,
underpins this evidence based, high quality, patient centric model of care. This model
is dependant upon access to referral points that are well supported by information
and education from injury prevention to first aid and multidisciplinary clinical
specialists care.
Current WA epidemiological data indicates decreases in hospital admissions and
readmissions in recent times. This decrease can be attributed to primary and
secondary prevention interventions delivered synergistically by non-government and
government agencies, advances in burns care processes and new technology that
promotes consultant led support for collaboration and integration of services.
Burn surgery is a rapidly advancing specialist field. Development of surgical and
rehabilitation techniques for tissue salvage and application of tissue engineering
technologies in addition to traditional techniques of wound care is continuous.
Dressing systems are advancing with new technologies. To implement the new
techniques we need to develop tools for assessment, support prospective research
and undertake clinical audit.
In addition, Burn Injury is one of the most common injuries to occur during mass
casualty events. Therefore, during the planning and response to a disaster, trained
burns specialists should be involved.
7
The purpose of this document is to provide a brief overview of the service delivery
models available nationally and the current status of the WA Burns Services locally. It
will also clearly articulate the Model of Care for Burn Injury for WA to establish a
model of care across the state to improve equitable access to services that will
prevent Burn Injury, provide better Burn Injury first aid and on-going care for all WA
burn injured patients. This will ultimately have had an impact on hospitalisation rates
and care outcomes.
8
2. Recommendations
To implement the Western Australian Model of Care for Burn Injury, it is
recommended that there is:
Recommendation 1:
Development, maintenance and expansion of existing injury prevention initiatives as
follows:
Expansion of existing child safety programmes in rural and remote areas
Development of targeted programmes for the 15-24 year old age group
Ongoing development of culturally secure ATSI resources for the prevention of
Burn Injury
Development of targeted education programmes in the use of child safety
resources for rural and remote health professional, Aboriginal health workers,
Aboriginal health services and Community groups.
Implementation of the WA Alcohol Plan strategies including social marketing
campaigns to policy targeting risky drinking behaviours.
Recommendation 2:
Consult with training organisations to ensure that all first aid training courses,
particularly for ‘at risk groups’ carers, work places and general community contain
burns first aid content.
Recommendation 2.1:
Provide access to basic online first aid training on Burn Injury to target the
community.
Recommendation 3:
Development of assessment techniques and prospective research as well as
prospective clinical audit is required to support implementation of innovative surgical
techniques.
Recommendation 4:
Establishment of state-wide burns e-health services with associated protocols and
guidelines and, supporting consultant led on-call advisory service for non-specialist
units in metro, rural and remote areas.
Recommendation 5:
Develop guidelines for wound management and rehabilitation, and audit to ensure
the WA Burn Injury Service standards are being achieved and maintained in non-
specialist units including work sites.
Recommendation 6:
Develop clinical protocols and risk assessment tools to assess mental health across
the continuum of care to ensure timely psychosocial intervention.
9
Recommendation 6.1:
Education for health professionals should include the roles, responsibilities and
requirements by health professionals in the setting where non accidental Burn
Injury is suspected in children.
Recommendation 6.2:
Burns Services should include a dedicated clinical psychology role to provide
specialist mental health services for Burn Injury patients.
Recommendation 7:
Develop programmes to assist patient integration back into the community including:
‘Medihotel’ type accommodation for step-down from tertiary care should be
available in metropolitan, rural and remote areas
Community Rehabilitation and follow up that includes education for children and
access to non- government community resources
‘Rehabilitation in the Home’ (RITH) for moderate and severe burn injured
patients
Planning for reconstruction procedures
Recreational therapy
Return to work/school planning
Psychological individual or group counselling
Linking with chronic injury support groups
Recommendation 8:
Develop and provide education packages and training for the appropriate transfers of
patients to regional, rural and remote facilities who will have first contact with burn
injured patients.
Recommendation 8.1:
Increase access to web-based training and e-health modalities to improve
training and education programmes for clinical workforce. This will require
increased resources to improve state wide e-health services with links to Wounds
West.
Recommendation 8.2:
Provide disaster preparation education which includes training on treatment of
Burn Injury for all pre-hospital and hospital health care providers in emergency
and critical care areas.
Recommendation 9:
Establish stronger partnerships between the Department of Health WA and
Australian Universities through clinical workforce initiatives to establish curriculum for
short modules or multi-disciplinary postgraduate programmes that focus specifically
on burns injury.
10
Recommendation 9.1:
Provide training and professional development learning opportunities through
Telehealth support for nurses and allied health professionals in rural and remote
areas.
Recommendation 10:
Provide individual training of all staff within Burn Injury Units in disaster preparedness
and disaster response training.
Recommendation 10.1:
Regular contact by the Burn Injury Units should be made with the State Health
Disaster Coordinators through provision of information to the Australian and New
Zealand Burn Association National Burns Registry and State Health Disaster
Committees.
Recommendation 11:
Support the current tertiary centres to develop as a virtually united centre of
excellence that makes a major contribution to the international literature for Burn
Injury management.
Recommendation 12:
Further investment and funding for the ongoing innovation and development of the
WA Burns Service Burns Information Management System at the Adult & Paediatric
Burns Services is required.
11
3. Definition of Burn Injury
Burn Injury was traditionally defined by percentage of total body surface area
(%TBSA) affected. This definition excluded many other factors that impact on a
person’s well-being. The classification is dependant on a range of variables that
describe the mechanism of injury, how the patient is affected by the injury, %TBSA
affected and depth of Burn Injury. Other clinical variables include: age, site of burn,
effect on airway, other injuries, co morbidities, and psychiatric and psychosocial
considerations. Assessment of these factors allows the Burn Injury to be defined as
minor, moderate and severe. Therefore burn injuries in WA are defined as:
Figure 1. WA Burn Injury definition
BURN INJURY ASSESSMENT

(mechanism of injury, how the patient presents, care required, (%TBSA)
MINOR MODERATE SEVERE
Different types of Burn Injury include flame burns, scalds from hot liquids, contact
burns from hot surfaces such as stoves, heaters, irons, electrical burns, chemical
burns, friction burns and radiation burns. The extent of the injury is dependant on the
degree of heat and length of time in contact with the heat. For example, flash burns
are generally less severe than scalds.
Assessment of the patient includes: inhalation injury, %TBSA affected, the site and
depth of the wound, the patient’s age, the presence of other injuries, any areas of
circumferential burns, co morbidities and psychosocial issues.
Treatment and referral pathway is also determined by the level of care required, such
as resuscitation verses no resuscitation, surgery versus no surgery/conservative
wound care. This definition and application of the ‘triangle of care’ will guide the care
pathway for each individual patient. The ‘triangle of care’ (Figure 2) is applied to
assist in determining if in fact the time, place and team present are right for the
patient at the point of contact.
Figure 2. Triangle of Care
What the patient needs to recover
Outcome
of injury
Resources Skills available at
available to the specific time of
optimise outcome care
12
4. Principles
The following principles underpin WA Health’s response and approach to prevention,
treatment and management of Burn Injury in WA:-
Care is patient centred and considers the needs of patients, families and carers
Care is provided through a skilled multidisciplinary team from primary,
secondary and tertiary levels
The patient’s journey occurred through health service delivery which is
integrated and comprehensive
Prevention activity takes a population-wide perspective and includes a
combination of universal and targeted initiatives.
Health care is delivered across the system by establishing and maintaining
strong partnerships between sectors and agencies
Care and service delivery reflect the evidence base and best practice
Services that are sustainable for all aspects of the model of care
13
5. Overview of Burn Injury
5.1 International
It is important to note, global data produced by the World Health Organisation
categorises Burn Injury into ‘fire related injury ‘. 1 , 2 This broad categorisation may
enhance the risk of underreporting of the extent of burn trauma, as scalds in children
are a major cause of injury worldwide.
Mortality rates from Burn Injury vary across regions of the world. Low and middle-
income countries suffer higher mortality and morbidly rates from burns. These
countries require improved surveillance of Burn Injury via epidemiology studies,
which will determine the incidence and prevalence of Burn Injury among sub
populations. This data will then allow government and nongovernment organisations
to design and implement effective prevention strategies. 3 High-income countries
have lower mortality rates due to implementation of a range of preventative initiatives
including legislation, social marketing and advocacy, as well as improved burn care
services. Advances in Burn Injury care enhancing functional outcomes, in conjunction
with increased emotional and practical support have improved quality of life for Burn
Injury survivors. 4
Despite these advances worldwide in year 2000 fire related burns were responsible
for 238,000 deaths. Globally, fire related deaths occur predominantly in females,
children 0-5yrs account for 15% of all fire related deaths and it is one of the top ten
causes of death in 15-29yr age group. Therefore, globally groups at most risk of fire
related injuries or death are young children and females in the 5-14 years age
group2.
5.2 National
Injury from fire burns and scalds are the sixth leading cause of injury in Australia and
was identified as one of seven National Health Priority Areas in 2002. The National
Injury Prevention and Safety Promotion Plan 2004-2014 defines priority areas for
action by states and jurisdictions to inform injury prevention programmes within
defined high risk population groups; children, young adults, adults, older people, rural
and remote populations, Aboriginal and Torres Strait Islander peoples and injuries
sustained in conjunction with alcohol use. 5 The principals and priority actions of the
framework have particular relevance to children, young adults and older people as
they are amongst the most high risk population for burn injuries in Australia.
The external causes of Burn Injury can be categorised either as thermal or non-
thermal. The majority of thermal burn injuries are non-intentional events, commonly
caused by exposure to hot fluids, fire or hot objects. Other less common causes of
thermal burn injuries include interpersonal violence or intentional self harm. Non-
thermal cases include burn injuries caused by explosives, electric current, corrosive
chemicals, friction, extreme cold and complications of medical and surgical care.
Contact with hot fluids are the most frequent cause of hospitalisation but are less
likely to result in severe injuries compared to exposure to uncontrolled fire and
intentional self-harm, which is a less common form of Burn Injury.
In 1997-2005 the rate of total Burn Injury related deaths for Australia was 0.5 per
100,000 persons. 6 In 2003-04 the age-adjusted hospitalisation rate of fire, burn and
scald related injury in Australia was 31.9 cases per 100,000 population per year7
14
During the period of 2001-02, throughout Australia, burns and scalds were
responsible for 6,248 hospitalisations in public hospitals with the average length of
stay being 7.1 days incurring an estimated cost of $132 million 7 .
The development of injury prevention strategies that reduce hospitalisation by 1%
saves 1.3 million per day and a new clinical therapy that improves healing and
reduces hospitalisation by just one day would save the health care budget
approximately $18 million per year on burn treatments alone. 8 Therefore there is a
need for collection of actual data rather than estimation, in order to gain an accurate
assessment of the burden of disease and injury. National data suggests young
children, males in their late teens and early twenties, and older persons are most at
risk of hospitalisation from burns and scalds.7
5.3 Western Australia

WA data on Burn Injury related mortality and morbidity is very similar to national data.
In comparison to national hospital admission rates, WA had a slightly higher rate in
2003/04 (Refer to Figure 3). This can be partly explained by the fact WA has a higher
ratio of non-metropolitan to metropolitan people compared to other states, where
non-metropolitan area rates of burn related injury are higher. Additionally, WA has a
large industry sector where burn related injury is common. WA also captures
approximately 98% of hospital admissions, compared to other states where data
collection is not as accurate.
5.3.1 Trends by gender
Figure 3 below also shows although there has been some variation in hospitalisation
rates for Burn Injury between 1988/89 and 2006/07, overall there has been a
decrease for both genders. 9 Similar to national trends, the WA male hospitalisation
rate for burns in 2006/07 was double the female rate. 9,10 A significant difference
between male and female rates have been prevalent since 1988/89.9
15
Figure 3. Hospital admission rates with a principal diagnosis of injury and a
2006/079
WA Males WA Females
WA persons Australia persons
80
Rate per 100,000 persons
70
60
50
40
30
20
10
0
5
7
9
1
_0
_0
_0
_0
_0
_9
_9
_9
_9
_9
_9
_0
_0
_0
_8
_9
_9
_9
_9
98
99
00
01
02
03
04
05
88
89
90
91
92
93
94
95
96
97
06
20
20
19
19
20
19
19
20
20
20
20
19
19
19
19
19
19
19
19
Year
Age-standardised per 100,000 population

Source: WA Hospital Morbidity Data System
5.3.2 Trends by age

WA data from 2004/05-2006/07 suggests groups most at risk of burn related injury
are young children, males in their late teens and early twenties and older people
(Refer to Figure 4).9 This is consistent with national data.7
Overall, children aged 0-4 years are most at risk of burn related injury. In comparison
to females and other age groups, males in the 15-19 and 20-24 age groups have
significantly higher crude rates of burn related injury.
Those aged over 85 years have few hospital separations but the number of deaths
caused by burn related injury in the older age group from 1997-2005 was the highest
for a particular age group (10 persons). An equal number of deaths were also
recorded for the 0-4 year age group.6 Overall WA data suggests prevention
interventions need to target young children, males in their late teens and early
twenties, and older people.
16
Figure 4. Hospital separations with a principal diagnosis of injury and a
2006/079
300 Male searations 160

Female separations
Crude rate per 100,000 persons
140
250
Male rate Female rate
120
200
100
150 80
60
100
40
50
20
0 0
4
4
4
9
4
+
–7
–2
–6
–6
–7
–8
–1
–1
–2
–3
–3
–4
–4
–5
–5
0–
5–
85
70
60
65
75
80
10
15
20
25
30
35
40
45
50
55
Age Group

5.3.3 Aboriginal population
Overall in WA, Aboriginal people experience higher hospitalisation rates for burn
related injury compared to the non-Aboriginal population (Refer to Figure 5). About
15% of all burn injuries in WA hospitals were among the Aboriginal population. Figure
5 shows that separation rates for Aboriginal Western Australians were more than five
times higher than the non-Aboriginal rate at 303.1 and 59.2 separations per 100,000
persons respectively. Aboriginal children, like non-Aboriginal children aged 0-4 years
are most at risk of burn related injury.9 Hospitalisation rates were four times higher
among Aboriginal children aged 0-4 years than non-Aboriginal children of the same
age. This rate of Burn Injury in Aboriginal people supports the implementation of
injury prevention programmes to target this injury cause.
17
Figure 5. Age standardised rate, all burns (a) by Aboriginal status, WA,
1999/00–2006/07

Non-Aboriginal Aboriginal
350
300
250
200
150
100
50
0
1999_00 2000_01 2001_02 2002_03 2003_04 2004_05 2005_06 2006_07
Table 1 below shows that among non-Aboriginal people in WA more than one in 20
separations for burns were deliberate self harm compared to 1.6% in Aboriginal
people. In contrast, 7.5% of burns separations among WA Aboriginal people were
the result of interpersonal violence, compared to 1.2% among their non-Aboriginal
counterparts.
Table 1. Proportions of hospitalisations for Burn Injury by cause, non

Aboriginal and Aboriginal in Western Australia 2004/2005-2006/2007
Non-Aboriginal (%) Aboriginal (%)

Transportation 4.4 2.6
Poisoning 4.2 1.7
Falls 1.0 0.2
Fires/Burns/Scalds 53.9 65.8
Unintentional (Other) 17.3 14.2
Self-Harm 5.1 1.6
Interpersonal Violence 1.2 7.5
Undetermined Intent 1.0 1.0
Medical Complications 5.4 2.8
Unknown 6.5 2.6
Data Source: WA Hospital and Morbidity Data System
18
5.3.4 Rural and remote population
Figure 6 below shows a comparison of hospital separations between metropolitan,
regional and remote regions in Western Australia, significantly higher rates of
hospitalisations occur in remote areas. Figure 7 below shows incidence by region in
Western Australia. Hospitalisation rates per 100,000 are highest in the Kimberley at
72.3, the Goldfields at 50.7, the Pilbara at 37.4 and at the Wheatbelt 35. A cross-
sectional survey conducted in 19 French Burn Injury Units found similar results in
rural areas. In addition this study showed Burn Injury in populations from rural areas
were more severe, deeper, involved a larger % TBSA with a higher rate of deaths
than in urban areas. Prevention strategies should be specifically adapted to the
profiles of burn patients. 11

injury and a primary cause of fire, burns and scalds, by region, WA,
2004/05-2006/079
100
90
Rate per 100,00 perons
80
70
60
50
40
30
20
10
0
Metropolitan Regional Remote
Region

19
injury and a primary cause of fire, burns and scalds, by health
region, WA, 2004/05-2006/079
140
120
100
80
60
40
20
0
Goldfields G reat Kimber ley Midwest NMAHS Pi lbara SMAHS South W heatbelt
So uthe rn West
Health Region

5.3.5 Types of Burn Injury

The most common mechanisms of burn related injury (WA hospital admission data
from 2004/05-2006/07) include contact with hot drinks, food, fats and cooking oils
(330 hospital separations); contact with hot fluids (291 hospital separations); and
exposure to ignition of highly flammable material (274 hospital separations). Other
less common causes of Burn Injury are from electric current, ionizing radiation, and
visible and ultraviolet light.
Table 2 below shows that for each of the causes presented, children aged 0-4 years
represent a significant proportion of those hospitalised; including:
Contact with hot household appliances: 57.3 per cent.
Contact with hot tap-water: 43.2 per cent.
Contact with hot drinks, food, fats and cooking oils: 41.5 per cent.
Contact with hot heating appliances, radiators and pipes: 40.9 per cent.
Contact with other hot fluids: 38.7 per cent.
The data below suggests the majority of burn related injury occurs in the home and is
associated with cooking. This is supported by a WA prospective review of minor Burn
Injury between 1 January 2004 and 30 November 2004, where 56.57% of cases
occurred in the home and 35.96% of burn injuries were associated with cooking. This
data has specific implications for prevention interventions.
20
Table 2. Injury related fire burns and scalds by age and cause WA 2004/05-
2006/07
0–4 5–24 25–64 65+ Total

Per cent N o.
E xposure to uncontrolled fire in building or structure 10.5 19 .3 64.9 5.3 57
E xposure to uncontrolled fire, not in building or structure 4.3 4 .3 78.3 13.0 23
E xposure to controlled fire in building or structure 16.7 30 .0 46.7 6.7 30
E xposure to controlled fire, not in building or structure 19.4 32 .8 47.0 0.7 134
E xposure to ignition of highly flam mable m aterial 1.4 47 .0 47.7 3.9 281
E xposure to ignition or m elting of nightw ear 33.3 0 .0 16.7 50.0 6
E xposure to ignition or m elting of other clothing and apparel 4.5 38 .6 45.5 11.4 44
E xposure to other specifi ed sm oke, fire and flam es 16.5 22 .8 44.3 16.5 79
E xposure to unspecified smoke, fire and flames 9.2 18 .3 61.8 10.7 131
C ontact w ith hot drinks, food, fats and cooking o ils 41.5 23 .9 25.6 8.9 347
C ontact w ith hot tap-water 43.2 10 .8 32.4 13.5 74
C ontact w ith other hot fluids 38.7 26 .5 26.5 8.3 302
C ontact w ith steam and hot vapours 2.9 30 .4 58.0 8.7 69
C ontact w ith hot air and g ases 7.7 30 .8 53.8 7.7 13
C ontact w ith hot household appliances 57.3 13 .3 25.3 4.0 75
C ontact w ith hot heating appliances, radiators and pipes 40.9 18 .2 30.7 10.2 88
C ontact w ith hot engines, m achinery and tools 14.3 60 .3 23.8 1.6 63
C ontact w ith other hot m etals 18.5 25 .9 55.6 0.0 27
C ontact w ith other and unspecified h eat and hot substances 18.4 25 .4 36.8 19.3 114
Total 24.6 28 .2 38.9 8.3 1,957
21
6 Causes of Burn Injury
6.1 Associated risk factors
Burns hazards in the home
A number of hazards in the home increase the risk of Burn Injury. Parental
awareness will provide a safer home environment, in particular for their children.
Examples of hazards include hot drinks, hot tap water, ovens, stoves, kettles, irons,
heaters, open fires, matches, lighters, chemicals and electrical outlets. 12
Cigarette, alcohol and drug use
Those who smoke, drink alcohol and use drugs have a significantly higher risk of
being injured or dying in a residential fire.12 Cigarettes are responsible for 28% of all
fires causing death. Often fires start from bedding or upholstery igniting. Alcohol was
an associated factor for 23.24% of cases recorded in the WA prospective review of
minor Burn Injury 13 and 44% of fire related deaths.
Open Fires
Open fires such as campfires, bonfires and barbecues used for cooking, heating and
lighting pose an increased risk of burn related injury. Inadequately extinguished
campfires leaving hot ashes and coals actually cause more burn related injury
compared to open flame fires. Children below the age of five who have poor
recognition of environmental hazards are particularly at risk of burns from
inadequately extinguished campfires. 14
Lower socioeconomic status
A recent study has confirmed several socioeconomic status (SES) factors are
associated with an increased risk of Burn Injury. These SES factors included ethnicity
(non-Caucasian) low income, large families, single parents, illiteracy, low maternal
education, unemployment, job loss, poor living conditions, not owning a home, not
having a telephone, and over crowding. The generalisability of these finding are
limited by varying definitions of SES, as well as the heterogeneity of study
populations and outcomes measures. However, this study has provided a list of
factors to be considered when developing prevention initiatives for Burn Injury. 15
Implications for prevention
The majority of these causes of Burn Injury can be directly influenced by prevention
interventions; low SES can be addressed but requires multiple interventions at social
and individual level. Those causes most influenced by prevention strategies include
burn hazards in the home, cigarette, alcohol and drug use as well as open fires.
Primary and secondary prevention approaches have the ability to prevent burns
related injury from occurring, in addition to increasing the application of correct first
aid, which can significantly reduce the “Burden on Disease and Injury” caused by
fires, burns and scalds. 16 Similarly, programmes targeting young Australians must
address social norms which perpetuate behaviours which contribute to Burn Injury
such as the use of alcohol, drugs and violence.
22
6.2 Target groups
The data presented above clearly demonstrates that the high risk groups in Western
Australia are:-
Aboriginal and Torres Strait Islander people
Rural and remote populations
Children 0-4 yrs
15-24 year olds, particularly young males
Elderly people
23
7. Proposed Model of Care for Burn Injury
7.1 Prevention
7.1.1 Current prevention strategies in WA
7.1.1.1 Fire and Emergency Services Authority (FESA) of WA
The FESA has three strategic intentions one of which is community-centred
emergency management, which incorporates aspects of fire and Burn Injury
prevention. Prevention is based around increasing community awareness of hazards
and community resilience to these risks. A number of the FESA programmes are
designed for remote Indigenous communities using Indigenous language and
communication methods where appropriate. 17
Smoke alarms warn people of a possible fire, which can prevent death or injury and
reduce property damage. To ensure smoke alarms are always functioning correctly,
the FESA encourages residents to test smoke alarms monthly and change batteries
once a year. The FESA promotes April Fools Day (1st April) annually as the day to
change smoke alarm batteries with a high-quality long-life battery.17
7.1.1.2 Kidsafe WA
Kidsafe WA has been successful in achieving legislative change to reduce bathroom
hot water temperature controlling hot water system delivery temperatures. Kidsafe
WA has also conducted a number of scalds prevention education campaigns “Hot
Water Burns Like Fire” in 1996, 1999 and 2001/02. Kidsafe WA through its Home
Safety Demonstration Home and 1800 toll free number provides ongoing advice to
parents on all aspects of child safety including products for the prevention of burns.
The Kidsafe website is an ongoing useful source of information for the community to
access information on burns prevention (http://www.kidsafewa.com.au/).12
On behalf of the WA Department of Health, Kidsafe WA conducts the following child
injury prevention programmes:
Home Safety Demonstration Home: This centre showcases a safe home
environment and child safety products to prevent injury in the home with
emphasis on appliances and safe products including protection from burn
injuries.
1800 Child Safety Information Line and Kidsafe WA Website: The line provides
an advice and information line for parents and the community on all aspects of
child safety. Development of the website in 2008 includes an interactive safe
home site (virtual walk though home) which can be accessed by the community
who cannot visit the Home Safety Demonstration Home. This will particularly
benefit the rural and remote areas of Western Australia.
The Injury Surveillance Bulletins: The quarterly reports provide information on
surveillance of injury types and causes of injury for children presenting to
Princess Margaret Hospital Emergency Department. Each bulletin showcases
a particular child injury cause and promotes strategies and activities to prevent
such injuries. The Bulletins are provided to the community, schools and injury
prevention officers across health services and health professionals and are
available on the Kidsafe WA Website.
24
The Child Seasonal Injury Prevention Programme: This is a multilevel
programme targeting at the 4 key child injury areas: falls, burns and scalds,
accidental poisoning and holiday safety. The programme focuses each key
area in line with the season where the potential for injury cause is highest. The
Burn Injury prevention programme “Get Warm Don’t Burn!” is conducted in the
winter period June to August when the potential of Burn Injury from hot food
and fire incidents is highest. The Child Seasonal Injury Prevention Programme
is conducted statewide including rural and remote communities in Western
Australia.
Resources for Indigenous populations: Additional funding has been provided to
develop child safety injury prevention resources for the Indigenous population.
These resources will build on the successful development of such resources by
Queensland Health utilising local research and consultation.
7.1.1.3 Western Australian Department of Health
The Government of Western Australia through the Department of Health funds focus
injury prevention programmes for high risk populations, which is aligned with the
principles and priority action areas under the National Injury Prevention and Safety
Promotion Plan 2004-2014. These programmes are conducted by non government
sector organisations under service agreements with DoH WA. The programmes
focus on population groups where admission to hospitals results from specific injury
causes and include, child safety, prevention of drowning and falls in older
Australians.
The Western Australian Department of Health injury prevention programmes are
aligned with Western Australian Health Promotion Strategic Framework 2007-2011.
This policy defined the strategic priority purchasing areas for health promotion and
injury prevention to enhance existing and implement new programmes for injury
prevention in Western Australia. This policy aligns with the WA Health Strategic
Intent 2005-2010 and the key priority area of Healthy Communities.
Child safety is defined as priority area 2 for injury prevention with particular emphasis
on the development of injury prevention programmes targeting accidental poisoning,
burns and scalds, playground safety and falls. The child safety and injury prevention
programmes, as described under the section 7.1.1.2, are conducted by Kidsafe WA
under several programmes.
While the Home Safety Demonstration Home has been established for a number of
years, the Child Seasonal Injury Prevention Programme and indigenous resources
are new programmes established in 2007. These programmes are funded until 2010
and will be evaluated as they are established and developed over the term of the
Service Agreement.
7.1.1.4 Drug and Alcohol Office
The role of the Drug and Alcohol Office is to present and reduce alcohol and other
drug related harm, including alcohol-related burn, in Western Australia and is the
government agency responsible for drug and alcohol strategies and services in
Western Australia.
The agency provides or contracts a state-wide network of treatment services, a range
of prevention programs, professional education and training and research activities. It
coordinates whole-of-government policies and strategies in conjunction with state
25
and commonwealth agencies. For example, the WACHS Brief Intervention Initiative
has introduced alcohol use screening and brief intervention for all people admitted to
hospital.
The Western Australian Drug and Alcohol Strategy (WADAS), provides the broad
direction for addressing problems relating to alcohol and other drug use in Western
Australia. There are a numbers of state and national policy papers and guidelines
that underpin the Strategy. These include, but are not limited to, the National Drug
Strategy 2004-2009, the WA Alcohol Plan and other strategies that guide practice.
Prevention and reducing alcohol-related harm are WADAS priorities. Activity to
prevent and reduce alcohol-related harm focuses on social marketing to decrease
the support for risky drinking and provide policy and environmental settings that
discourage and make it difficult for people to engage in risky drinking.
The majority of acute harms such as alcohol-related injury, including burns, tend to
arise from episodic bouts of intoxication. Drinking to the point of intoxication is
widespread in the community, highly prevalent among young males, aged 17 to 30
years-of-age and people in the northern and central regions on non-metropolitan WA.
A prevention paradox exists with regard to acute harm and intoxication, whereby
those who occasionally drink at risky levels constitute a far larger group than the few
community members with ongoing drinking problems. Therefore, contrary to popular
opinion, the attributed burden of harm is greater for this group who occasionally drink
than those with a drinking problem.
Furthermore, intoxicated adults do not supervise children as well as their non-
intoxicated counterparts, leaving children at greater risk of harm. The extent that
intoxicated adults directly or indirectly contribute to the burn injury suffered by
children is not known.
Therefore, strategies to decrease the prevalence of risky drinking in the WA
population reduce alcohol-related harm, including burn injury and are detailed in the
WA Alcohol Plan.
For 2004/05, it is estimated that risky alcohol use cost Western Australian society
$1.5 billion. These costs include the aggregated costs due to alcohol-related harms,
including burns.
7.1.1.5 Area Health Service Initiatives WA Health
The Prevent Alcohol and Risk related Trauma in Youth (P.A.R.T.Y) Programme is
conducted by Royal Perth Hospital, South Metropolitan Area Health Service. The
PARTY Programme targets 14-18 year olds and is an awareness campaign which
demonstrates the consequences of risk behaviours such as the use of alcohol and
the serious impact of trauma. The programme influences this group to recognise
potential injury situations and change behaviours to minimise risk of injury. This
Programme is supported by the Adult Burn Injury Unit which provides education on
the potential for Burn Injury in this setting.
The Adult Burn Injury Unit also supports an education programme to ‘fire lighters’
who are not eligible for the Juvenile and Family Fire Awareness Programme (JAFFA)
Programme. The programme is conducted in the Burns Injury Unit at RPH where
programme participants are given information on the consequences for people with
Burn Injury and targets the 10-17 years age group. The programme is also
conducted in schools.
26
7.1.1.6 Legislation
Labeling on children’s nightwear
National legislation adopted under the Western Australian Fair Trading Act 1987
regulating flammability of sleepwear is effective in reducing burn injuries. In 1978
it became mandatory in Australia for all children’s nightwear to contain a label
indicating garment flammability (Australian Standard 1249-1999) Labeling on
children’s nightwear is split into three categories, “low fire danger”, “styled to
reduce fire danger”, and “warning- high fire danger- keep away from fire”. Parent
education as well as style changes (from nightgowns to pyjamas) have
contributed to burn prevention.12
Safe water temperatures and safety products
The most effective documented method of preventing scald burns is legislation
requiring all water heaters have a safe pre-set temperature. This legislation has
been found to be more effective than parental education in encouraging parents
to turn down water heater temperatures. 18 Australia wide hot water temperature
control has been legislation since 1997. This legislation applies to all new
buildings and sanitary fixtures including basins, baths and showers. In domestic
houses the maximum temperature of water allowed is 50oC and in early
childhood centres, schools, hospitals and aged care facilities it is 45oC.
Smoke alarm legislation
Hard-wired smoke detectors have been mandatory in all new residential
properties and major renovations in WA since the Building Code of Australia was
amended in 1996. There is no current legislation in WA for residential properties
built prior to 1996; hence new legislation is currently being developed. The FESA
and the Department of Housing and Works are working on developing
amendments to the Building Regulations which will require hard-wired smoke
alarms to be installed in all residential (including rental) properties before they
can be sold or re-tenanted. The intent of this legislative amendment is to ensure
hard-wired smoke alarms are installed in all residential properties, not just those
constructed after 1996. The amended Building Regulations will be prescribed
under the Local Government (Miscellaneous Provisions) Amendment (Smoke
Alarm) Bill 2007 (the Bill). 19
27
7.1.2 Proposed strategies for injury prevention
7.1.2.1 Injury Prevention Framework
The Injury Prevention Working Group (IPWG), a subgroup of the Injury and Trauma
Health Network has evaluated several models including Haddon’s Matrix to inform
the development of an injury prevention framework which can be applied in the
Western Australian Models of Care for injury and trauma. One such model
developed by Professor David Sanders describes a framework model applicable in
public health prevention of disease 20 The IPWG used the public health model to
develop a modified Injury Prevention Framework, as outlined in the table on p.30,
which can be applied in the Models of Care for injury and trauma.
The primary outcome of the Injury Prevention Framework is to create a safe and
supportive environment that reduces the risk of an injury occurring. This Framework
allows for preventative measures to be identified across all components and
therefore across continuum of care. The key components of the framework are:
Promotive (target – well population)
Preventive (identified at risk group/population)
Curative (acute care of injured individual)
Rehabilitative (rehabilitation aspect in the treatment of injury)
To ensure sustainable reduction of burn injuries in the community, actions at the
national, state and regional level are required. A comprehensive integrated
programme consisting of the evidence based initiatives and strategies, outlined in the
framework below, needs to be developed.
28
Injury Prevention Framework
Universal Selective
Promotive Preventive Curative Rehabilitative

strategies strategies strategies strategies
Well population At risk population Acute Chronic
Education Assess and Education Education

identify ‘at risk’
Policy population Inform Inform
according to
Legislation *geographical Brief intervention Community
location support
Advocacy *age Home assessment
*gender Client/carer
Partnerships (ie linking or *environment Discharge planning support
collaborating with NGOs, (SES?)
state and local *ethnicity Discharge packs Care plan
organisations)
Identify specific Workforce development Partnerships
Media actions within
each of the Resources Referral processes
Community following *Human resources
Engagement/Support/Action strategic areas: *Physical resources Workforce
*Education (infrastructure) development
Workforce development *Policy
*Legislation Resources
Resources *Workforce *Human
*Human resources development resources
*Physical resources *Resources *Physical
(infrastructure) (human and resources
physical) (infrastructure)
A holistic multidisciplinary approach has been taken in developing the framework

which outlines the key priority areas for the prevention and management of injury and
trauma. The framework allows for the identification of preventative strategies and the
optimisation of opportunities for injury prevention at all stages across the continuum
of care.
29
The key elements which underpin the framework include:
1. The ‘at risk’ population will vary depending on type of injury
2. The selection of the targeted population must be supported by relevant system
level statistical data such as prevalence rates, and/or utilisation of health
services as a result of injury.
3. Implementation of effective prevention programmes requires a competent
workforce with the capacity to deliver evidence-based primary and secondary
prevention activity at a level that can make difference.
An effective prevention programme integrates a coordinated national, state-wide and
local area, culturally sensitive approach. That is, culturally appropriate for Aboriginal
and, Culturally and Linguistically Diverse (CALD) groupsApplication of this model
with regard to targeted programmes for Burn Injury is supported in current
programmes in development or in place for child safety and limited intervention for
the indigenous population in Western Australia. However, there is clearly opportunity
to develop injury prevention strategies to target 15-24 years age group particularly in
young males. Ongoing expansion of programmes targeting Indigenous peoples are
also required for all ages groups. Aboriginal peoples in Western Australia are
fourteen times more likely to be admitted to hospital as a result of injury than non
indigenous people 21 . The implementation of strategies to reduce the prevalence of
risky alcohol consumption resulting in intoxication must receive priority for action.
7.1.2.2 Electrical outlet covers and electrical safety switches
The American Academy of Paediatrics recommends the use of plugs or covers on
unused electrical sockets to prevent electrical burns. Safety trip switches to prevent
electrocution have been regulated under the Building Code of Australia 22 in new
buildings or renovations in States and Territories for some time and are regulated
through local government bodies. There is an ongoing need to raise community
awareness for these devices to be installed in many older buildings and homes
constructed before these standards were implemented in 1996. This is particularly
relevant in older buildings as the potential for fires through faulty and old wiring and
products is higher.12. Although recent legislation passed in WA in 2007 prescribes
the installation of such devices in all residential buildings, community awareness of
this requirement and the benefits of such devices are still required.
7.1.2.3 Community education
Ongoing community education is required to increase awareness of burn hazards
and safety products.7 Safety products, such as cups with wide bases or lids and
barriers around kitchen stoves, irons and heaters play a role in preventing burns 23 in
children. Similarly antenatal education in regard to hot liquid safety when sterilising
bottles or preparing bottled water for baby can reduce risk of Burn injury for not only
the baby but also the mother and toddler in the family.
30
Each new generation of parents requires education on safety products and be
informed about the relationship between the stages of their child’s development and
injury risks. 24 Successful injury prevention education campaigns focus on a specific
prevention message targeting a narrow target group. Targeted educational
programmes for parents of young children and primary school aged children have
been successful. Programmes are more successful when a combined approach is
used involving a variety of community organisations, schools, the media, health
professionals and government. 25
Community education should also focus on the importance of smoke alarms.
Increasing ownership of smoke alarms is important, as studies have found fire skills
training does not correlate with correct behavior in real-life fires.12
A number of education campaigns focus on prevention of Burn Injury among children
in the home, however other risk situations need to be considered, such as campfire
burns.14. This is particularly significant for the Aboriginal 0-4 year age group.
Recommendation 1:
Development, maintenance and expansion of existing injury prevention programmes
as follows:
Expansion of existing child safety programmes in rural and remote areas
Development of targeted programmes for the 15-24 year old age group
Ongoing development of culturally secure ATSI resources for the prevention of
Burn Injury.
Development of targeted education programmes in the use of child safety
resources for rural and remote health professional, Aboriginal health workers,
Aboriginal health services and Community groups.
Implementation of the WA Alcohol Plan strategies including social marketing
campaigns to policy targeting risky drinking behaviours.
Department of Health Service Agreements with non government organisations for

child safety programmes includes reporting outputs to provide evidence to monitor
outcomes to deliver key outcomes. However, formal evaluation of the effectiveness
of specific injury causes requires ongoing monitoring of health service utilisation and
academic injury prevention research. Western Australia does not have system level
injury surveillance data information system. This limits capacity to formally evaluate
the effectiveness injury prevention programmes.
31
7.2 Burn Injury management
7.2.1 Pre hospital care/immediate care
Ongoing state-wide community education of appropriate first aid measures for burn
related injury is required in WA. Currently the Red Cross, St John Ambulance Service
(SJAS), and Royal Life Saving Society WA (RLSS) provide a wide range of high-
quality, accredited first aid courses and first aid products to the WA community. 26,27
For example SJAS held a Save a Life Day, on 16 May in 2007, where basic first aid
and resuscitation was taught to 3,907 students from metropolitan and country
locations. This event achieved a world record for the largest CPR training session.26
A WA prospective review of minor Burn Injury between January 2004 and November
2004 found 61% of cases recorded received inadequate or inappropriate first aid.13
Therefore educating children and adults’ basic first aid in a range of settings through
initiatives such as the Save a Life Day on an ongoing basis are recommended.
Data indicates an increased incidence of Burn Injury in rural areas compared to
metropolitan areas. Children in remote and rural areas have an increased incidence
of Burn Injury relative to the metropolitan population. In addition, indigenous children
who reside predominantly in rural/remote areas have a high incidence of injury and
complications e.g. infection.
Collaborative research is being conducted at the University of WA (UWA) to improve
patient assessment in WA. A computer based tool to guide assessment is being
researched and there are plans to develop an environmentally and culturally
appropriate targeted prevention and first aid programme.
Similarly, the West Australian Country Health Service (WACHS), Alcohol Brief
intervention initiative should be delivered state-wide.
These projects will provide tools to support improved pre-hospital and immediate
care.
Recommendation 2:
Consult with training organisations to ensure that all first aid training courses,
particularly for ‘at risk groups’ carers and general community contain burns first aid
content.
Recommendation 2.1:
Provide access to basic online first aid training on Burn Injury to target the
community.
32
7.2.2 Transport/transfer
Emergency Department (ED) costs decrease and workflow improves with appropriate
triage and transfer of burns patients. 28
Western Australia’s geographic characteristics present a significant challenge in the
provision of the right care at the right time.
Burns patients can be considered in 3 groups:
Inner Metro
Outer Metro
Rural/Remote
Patients within the inner metro group can access tertiary facilities directly. Those
within the outer metro and rural/remote groups require routine links to the tertiary
facilities, including protocols driven by the core multidisciplinary team.
A written transfer protocol should exist between Emergency Departments and Burn
Injury Units. 29 The transfer protocol should:
Identify appropriate stabilisation
Outline which patients need to be transferred
Determine who organises a suitable mode of transport
Identify patient needs during transportation
Outline resources available for clinicians caring for patients in outer
metropolitan, rural and remote areas that do not require transfer to PMH or RPH
burns unit (e-health services, online protocols)
The facility who has first contact with Burn Injury patient/s should contact the Burn
Injury Unit to gain support and advice regarding transfer of patient/s to a Burn Injury
Unit in the shortest possible time. The involved transport, ambulance and secondary
level care staff may require additional knowledge and skills in burn care, beyond the
emergency response stage. 30
A culture of an agreed and understood framework for access to services is a key
component for ensuring smooth transition from pre-hospital to integrated hospital
care.
33
7.2.3 Access to services
The following flowchart (Figure 8) guides the pathway for access to Burn Injury
services in WA.
Access to WA Burn Injury services is dependant on the post assessment
classification of the Burn Injury as minor, moderate or severe. The definition of minor,
moderate and severe Burn Injury will be further developed within a Clinical Practice
Guidelines for Burn Injury. The guidelines will define specific assessment criteria and
appropriate care pathways for burn injured patients. This classification will direct the
patient’s triage to a specific care pathway. It is important to note that Burn Injury
wounds are as dynamic and individual as the people who suffer them therefore
repeated ongoing assessment is required over time and subsequent assessments
may alter the care pathway. Each referral point must be supported by specialist
opinion.
34
Figure 8. Pathway for access to Burn Injury services in WA
PRE-HOSPITAL CARE
BURN INJURY ASSESSMENT

(assessment criteria needed - %TBSA, site & depth of the injury,
patient’s age, other injuries, co morbidities, psychosocial issues,
mechanism of injury, how the patient presents, care required)
Regional/Rural/Remote E-health Outreach to non-specialist centres
Conservative Wound Conservative Wound Surgical Repair

Care Care Resuscitation
No Resuscitation Resuscitation
Conservative path Multidisciplinary inpatient’ care

a) Home a) Adult Tertiary Burn Injury Unit
b) Local surgery (Royal Perth Hospital)
c) Day stay unit b) Paediatric Tertiary Burn Injury
Unit (Princess Margaret Hospital)
Supported by
Regional/Rural/Remote e-
health Outreach Service Provide Regional/Rural/Remote e-health
Outreach Service
Facilitated early discharge by:

a) Hospital-in-the-Home services
b) Step down to local non-tertiary
hospital for transition to
rehabilitation.
35
7.3 Care considerations
7.3.1 Assessment
To deliver safe, high quality health care, accurate assessment and intervention is
crucial.
The initial assessment of a Burn Injury informs a plan of care, which is developed,
documented and reviewed for each patient on a continual basis. 31 Accurate and early
prediction of burn depth is vital to the management of severe burns, which often
involves early surgery. Determining burn depth has been based on expert clinical
judgement.31 Laser Doppler technology is being introduced to the WA Burn Service
to facilitate more precise assessment of Burn Injury.
Burn Injury assessment is notoriously difficult therefore access to specialist services
for guidance to appropriate assessment, definition/classification and treatment is
essential. The access to specialist guidance may be on-site or off-site, with e-health
supported informed, decision making, about the predicted evolution of the Burn Injury
and required care. In addition, care for non severe burn patients is provided by
networking with other WA hospitals by the Adult and Paediatric Burn Injury Units.
Most often, initial assessment of burn injured patients, is carried out in Emergency
Departments (ED). 32 Emergency Departments often have to treat Burn Injury, with
no access to a specialist Burn Injury Unit in the same facility. In this case it is
recommended ED staff communicate with the state Burn Injury Unit regarding patient
management. The WA Burn Injury Service via this model of care aims to provide a
twenty-four hour turn around service where staff from rural and remote areas, outer
metropolitan regions and GPs can email images to RPH and PMH for clinical advice.
A recent study has investigated using quantitative image processing of Burn Injury
photographs to aid in the assessment of Burn Injury. Research included collecting
data on widespread clinical photography techniques. Consultation with clinicians
concluded utilising a semi-automated image processing system, one photograph of
Burn Injury can possibly be used to estimate %TBSA of a Burn Injury. A database of
photographs of Burn Injury is required in order to do additional research in this
area. 33
7.3.2 Minor burn
Patients with minor Burn Injury are often treated outside specialist Burn Injury Units
or trauma hospitals. This provides a challenge for medical staff that does not treat
Burn Injury on a regular basis, as burn wounds evolve and potentially increase in
depth after the initial assessment and up to 72 hours post injury.
Therefore if at any time a minor burn increases in severity beyond that classified as
minor the patient should be transferred to a Burn Injury Unit as soon as possible.
Appropriately timed transfer and care minimises complications and patient length of
stay in hospital. 34
36
Communication with the most appropriate Burn Injury Unit is recommended for all
minor burn cases, even if those at the initial point of contact are confident about the
assessment and associated plan of care. This will ensure access to expert advice,
optimum patient treatment and early orientation for the specialised unit if
complications occur. This engagement with a Burn Injury Unit will facilitate non-
specialist facilities to develop emergency, stabilisation and transfer guidelines.30
7.3.3 Moderate burn
Similarly, moderate Burn Injury may be treated outside of a specialist Burn Injury
Unit. Resuscitation is often limited to uncomplicated airway management and fluid
replacement. If the initial assessment of ‘no surgery required’ remains accurate after
the first 48 hours then transfer to a specialist unit may still be necessary. Again, early
communication with the most appropriate Burn Injury Unit is also recommended for
all moderate burn cases along with adoption of the specialist units’ recommended
emergency, stabilisation and transfer guidelines.30
7.3.4 Severe burn
As per the definition outlined (p.12) a severe burn patient indicates a major burn and
all those requiring surgical intervention. Burn Injury Units located at RPH (Fiona
Stanley) and Princess Margret Hospital (PMH) provide care for severe burn patients
in WA. The role of these Burn Injury Units is to:
Provide high standard burn care embedded in an infrastructure for ongoing
research
Receive statewide referrals of severe burn patients
Provide leadership and expertise in burn care
Promote best practice in research, education and clinical care 31
Support e-health initiatives with virtual/electronic ward rounds that include a
review of all burn patients state wide initially, with digital images then progress to
increased use of e-health. Daily ward rounds and examinations of patients
returning home should include initial assessments and protocol guidance.
Multidisciplinary teams within the Burn Injury Unit should coordinate individual clinical
pathways for patients. The multidisciplinary team approach is consistent with best-
practice burn care. 35 Each clinical discipline in the multidisciplinary team should
provide input for a thorough treatment plan based on standardised, valid outcome
measurement tools. All care pathways must incorporate rehabilitation throughout all
stages of care starting at the time of injury.30
Allied health disciplines involved in the provision of care to severe burns patients may
include clinical psychology, nutrition and dietetics, occupational therapy, orthotics,
pharmacy, physiotherapy, play therapy, speech pathology and social work. For each
allied health discipline there are detailed referenced clinical practice guidelines.
37
7.3.4.1 Paediatrics
Fortunately large burns are an infrequent occurrence in paediatrics relative to adults.
To ensure the optimal outcome is achieved in paediatrics, a level of experience must
be maintained among professionals. There is currently not enough paediatric activity
in WA to ensure maintenance of severe Burn Injury skills for the existing
multidisciplinary team. The paediatric Burn Injury Unit will be supported by the adult
Burn Injury Unit. There is the need for paediatric anaesthetics and intensive care unit
capability. It is recommended nurses and therapists rotate into the adult environment
to maintain their knowledge in treatment of large burns. This rotation of staff allows
for exchange of ideas and the potential to improve care. For example, the ‘Bali
Bombing’ (2002) disaster response involved PMH staff assisting at RPH with
excellent results.
An emerging group is the adolescent with scarring and associated functional and
psychological problems. In collaboration the RPH and PMH Burn Units are
developing a transition programme to facilitate care beyond 16 years of age through
the final growth periods and beyond.
7.3.4.2 Surgical intervention
Perioperative care of patients with severe Burn Injury requires cross-disciplinary
planning and organisation of surgical, anaesthetic and intensive care personnel. This
is particularly important for those patients who have surgery commenced while being
managed in the Intensive Care Unit.31 A significant aspect of perioperative
management of severe Burn Injury includes post-procedural application of dressings.
These procedures are often extensive, complex and labor-intensive. The requirement
for positioning and splinting frequently requires the expertise of the burn
physiotherapist or occupational therapist in the surgical team.31
Surgical intervention is predicated on the condition of the patient and the burn
wound. There are approximately 150-210 severe Burn Injury Unit admissions per
year, of which approximately 45% of patients require surgical intervention. Patients
requiring surgical intervention from regions without burn surgery specialists on-site
will need stabilisation and transfer to a specialist unit, in a timely manner.
The WA severe Burn Injury service approach to surgical management of the burn-
patient is as follows:
Emergency surgery within 24-hours post-Burn Injury to prevent complications
associated with deep burns, often involving muscle or other tissue
Early excision of the necrotic burn tissue (3-5 days post full thickness, 5-10 days
post partial thickness burn-injury)
Coverage with a skin graft or skin substitute
Secondary wound coverage
Scar revision
38
Burn surgery is a rapidly advancing specialist field. The epithelial autograft
programme is a process directed at development of surgical techniques for tissue
salvage and application of tissue engineering technologies in addition to traditional
wound care techniques. Similarly, dressing systems are advancing rapidly with new
technologies. To safely implement the new and innovative techniques we need to
develop tools for assessment, develop prospective research and undertake clinical
audit. Under the inaugural Stuart Wagstaff Fellowship from Telethon, the Laser
Doppler Scanner is in use to evaluate assessment which brings together technology,
assessment and clinical audit.
Development of modalities for the rapid assessment of burn wound depth is a priority
for many health professionals specialising in burn wound management to guide
treatment and care. 36
Recommendation 3:
Development of assessment techniques and prospective research as well as
prospective clinical audit to support implementation of innovative surgical techniques.
7.3.4.3 Respiratory complications

At the time of Burn Injury from flame or smoke or toxic chemicals a person’s airway is
vulnerable and may be compromised even in the absence of burns to the face 37 .
Invasive and non-invasive techniques are often utilised to maintain the airway. These
interventions coupled with prolonged bed rest or theatre time may exacerbate
existing injury or increase the risk of respiratory complications if the airway is not
managed well. The development of respiratory complications increases mortality and
morbidity (including prolonging the length of stay); hence aggressive prophylactic
respiratory physiotherapy is essential.31
39
7.3.5 Special considerations for all burn patients
7.3.5.1 Rural and remote (including international and inter-state)
Treating and stabilising burns patients in rural and remote areas or in response to a
call for assistance from international or inter-state health services is a significant
challenge.30
The predominant issue for patients living in rural and remote areas is access to
expert burn advice and care. E-health technologies can alleviate distance, transport,
accommodation and cost issues for families having to travel to Perth from rural and
remote areas for expert burn care. The transfer of information via e-health provides
support to all staff involved in burn care regarding diagnosis, education and
treatment. Burn management is suited to e-health as it encompasses a high level of
visual assessment. E-health is also used as a teaching tool to build on current
knowledge in rural and remote areas. The main concerns with e-health are cost
effectiveness, confidentially and security of information/patient records, patient
consent, and professional indemnity as well as litigation. 38 Additional barriers are
access to appropriate and adequate analgesia and the multidisciplinary team.
Evidence of evaluation in the literature of telehealth programmes in burns care is
limited, particularly in relation to direct cost benefits and/or cost savings and in the
Australian context.
E-health can influence community based care, tertiary referral and hospital admission
rates. Virtual e-health clinics can review patient burn wounds, scars and movement,
which saves time and transport costs for the patient, family and health care system.
An e-health system encompassing visual communication would enable Burn Injury to
be reviewed on a regular basis by experts in burn care. To be effective and safe the
process must achieve high accuracy and reliability.38 Studies have found the quality
of digital imagery does enable accurate wound assessment and decision making. 39,
40
Experience in other state jurisdictions has demonstrated benefits.
A virtual outpatient burn care service for post-acute care of children in rural and
remote areas of Queensland has been trialled and documented. This service
provided 293 patient consultations over three years and reduced the need for
patients to travel to the state Burn Injury Unit in Brisbane.
It was successful in delivering post-acute burn care using videoconferencing, email
and the telephone. Services included routine specialist clinics via videoconference,
patient consultations during acute presentations and clinical advice for collaborative
burn management as required.
Satisfaction surveys from families of patients revealed a high level of satisfaction,
particularly in regard to saving time, money and stress, although the response rate
for the survey was low at 19%. Overall, the service improved access to specialist
services for rural and remote areas in Queensland 41 and this type of communication
system would build clinical expertise into rural and remote areas of WA.
40
Given the size of rural and remote Western Australia, this service would provide
treatment closer to home, reduce financial costs of travel to metropolitan areas for
follow-up care, and reduce disruption and separation from family and support
systems, particularly for Aboriginal patients who suffer significant psychological
stress on separation from their community and people. It would assist WA Health to
provide equal access to health care, in particular closer to the patient’s residence and
meet the increasing expectations of the community. Currently, Clinical Nurse
Consultant or Burns Fellow at WA State Burns Service provides remote consultation
to rural and regional hospital providers who are unable to access e-health services.
Appropriate assessment and referrals are advised based on the digital images of the
burn injured patients sent through to the Burns Consultants at WA State Burns
Service.
Where e-health treatment options have failed or are inappropriate access to retrieval
services with strong links to Burn Injury Units and management protocols should be
utilised.
Recommendation 4:
Establishment and maintenance of statewide burn e-health services with associated
protocols and guidelines and, supporting consultant led on-call advisory service for
non-specialist units in metro, rural and remote areas.
7.3.5.2 Wound management

Minor and moderate burn injuries should be healing adequately after 10-12 days. 42
However, delayed healing will result in increased risk of hypertrophic scar, functional
and psychological problems. The use of conservative wound care protocols will
assist to reduce the risk of infection, oedema, secondary functional disability and cost
of dressings. In most cases, the superficial burn can be managed well in the primary
care setting. The transfer of such a patient to a tertiary centre will only be necessary
if the burn area is such that IV fluid resuscitation is required or non-accidental injury
is suspected.
Alternatively, severe burn wound care is complex, time-consuming and painful. While
comprehensive nursing care is provided in the Burn Injury Unit, critically ill patients
managed in the Intensive Care Unit require coordination of wound care by the
nursing staff in the Burn Injury Unit, who are experienced in the management of Burn
Injury.31
Recommendation 5:
Develop guidelines for wound management and positioning, and audit to ensure the
WA Burn Injury Service standards are being achieved and maintained in non-
specialist units.
41
Inadequate oedema and scar management can lead to an increase in contracture
formation, as well as poor functional and cosmetic outcome. Oedema management
in the acute phase of burn treatment is essential. Oedema can delay wound healing,
promote formation of thick scar tissue and loss of movement. A variety of techniques
are used to manage oedema during this phase. Oedema management is the
responsibility of the occupational therapist/physiotherapist and nursing team. This
responsibility continues into the rehabilitation phase of care where the combined
effort of the multidisciplinary team is aimed at managing oedema, scarring and
contracture formation.
Moderate and severe burn injured patients are in the high risk category for pressure
area development according to the Braden scoring protocol; as they have reduced
levels of mobility and skin integrity is compromised. Pressure area prevention and
treatment is another major feature of burn wound management.
7.3.5.3 Infection control
A major clinical focus in the management of severe burns is infection control.
Patients with burn injuries are at a high risk of infection. Necrotic burnt tissue
provides an environment for the proliferation of microorganisms exposing the patient
to the risk of infection, delayed healing and complications. As such, meticulous
attention is integral to the management of the burn wound. The Burn Injury team
maintains close liaison with microbiology and infection control personnel, particularly
in relation to the maintenance of patient-related and environmental and architectural
infection control programmes.31 The use of directed and conservative infection
control protocols will reduce the risk of infection and assist to reduce the associated
cost of increased length of stay, due to delayed healing and increased functional and
psychological problems.
7.3.5.4 Medication and pharmaceuticals
The provision of medications and pharmaceutical products for the patient with a Burn
Injury may include:
Analgesics for acute, chronic and neuropathic pain
Antibiotics for the treatment of infection
Electrolyte and vitamin supplements
Medications to reduce pruritis and assist in wound healing
Antidepressants and nicotine replacement and medications to manage drug
withdrawal
The Burn Injury Team works closely with the pharmacist in the management of
patient care.31
42
7.3.5.5 Pain management
Burn Injury causes both physiological and psychological pain. The nature of burn
care frequently involves protracted surgical and non-surgical procedures, which
cause episodes of increased pain. In addition, the individual’s experience of pain,
both qualitative and quantitative, varies widely over the course of burn recovery, and
the need for different types and quantity of analgaesic varies accordingly. 43
Commonly patients experience longstanding pain or ongoing paraesthetic /pruritic
(itching) sensations in their scars for many years following injury.
Patients admitted to the WA Burn Injury Services are provided with a comprehensive
pain management service incorporating a range of pain management modalities.
Effective pain management is an important goal in the provision of care for the burn
patient. Nursing staff work closely with other disciplines regarding assessment,
delivery and evaluation of patient requirements for pain management. The
importance of acute pain management cannot be underestimated, as pain
experienced during hospitalisation has been shown to be significantly correlated with
psychological adjustment years after injury. 44 In addition to acute pain management,
the service provides treatment for chronic pain and neuropathic pain.
A range of therapeutic approaches to the management of acute pain include:
Patient Controlled Intravenous Analgesia (PCA) with or without sedation
Continuous narcotic infusions
Slow-release opiates and pain-relieving medications
Inhalational agents such as nitrous oxide
A variety of non-opiate analgesics
Appropriate addition of anxiolytics or sedatives31
Anti-emetics and aperients for gastric consequences
Complementary therapies, patient and carer education and non-pharmacological
pain relief also play an important role in pain management. Non pharmacological
interventions incorporate the critical aspect of the patient’s ability to psychologically
cope with pain associated with Burn Injury. The association between self-efficacy for
coping with pain and development of chronic pain syndromes is now well
documented. Therefore, patients’ experience of pain and perceived ability to cope
should form part of routine psychological assessment, with interventions being
provided, if indicated. While further research is needed to establish the efficacy of
specific psychological interventions in both inpatient and outpatient settings, there is
evidence to suggest hypnotherapy, sensory focusing, active distraction and cognitive
techniques all have the potential to decrease pain and/or the patient’s perceived
ability to cope. 45 The psychological treatment approach will depend on the individual
patient’s presentation and the stage of burn recovery.
The management of symptoms of pruritis associated with wound and skin graft
healing is a particular challenge following Burn Injury. WA Burn Injury service
employs treatment options such as antihistamines, topical applications, vibration and
bioptron.31
43
The pain management approach provided for burn injured patients is one of multi-
modal, high baseline, adjunctive and regular analgesics. It is provided
prophylactically in this manner, rather than on request, to maximally relieve pain
while supporting the patient to maintain their active functional and purposeful
movement.
7.3.5.6 Nutrition
Nutritional support is a vital component in the care of the severe Burn Injury patients
as optimal nutrition reduces length of stay, mortality, rate of wound
infections/sepsis, 46 severe weight loss, muscle wasting as well as improves wound
healing. 47 A dietitian should be involved in the nutritional management of patients
with severe burns, as soon as possible eg immediately on admission. The dietitian
will assess the patient, determine his/her nutritional requirements and instigate
appropriate nutritional support based on evidenced and peer supported nutritional
guidelines.31
The hypermetabolism associated with major burns results in an increased resting
metabolic rate in adults. 48 The standard practice for burn inpatients who are able to
take an oral intake is to be on high protein/high energy diets. However, those with
severe Burn Injury require an increase in nutritional intake via Enteral Feeding.
Enteral Nutrition is recommended over Parenteral Nutrition due to decreased risk of
infectious complication, mortality and cost. 49,50 Parenteral Nutrition should only be
used if Enteral Nutrition is contraindicated. Enteral Nutrition for patients with severe
burns should be commenced as early as possible post fluid resuscitation, preferably
within 24 hours of injury based on International Guidelines. 51, 52 Where possible
weight and height measurements should be obtained (or estimated), as these are
necessary to calculate energy and protein requirements. Weight should be monitored
weekly (or as practical).
For those patients on Enteral Nutrition, blood sugar levels should be monitored and
hyperglycaemia treated, as it is associated with poorer outcomes in adults with
burns. These outcomes include increased mortality, poor wound healing, reduced
skin graft take, increased rate of muscle protein catabolism and impaired immune
function. 53, 54, 55, 56 Early and ongoing nutritional support is a vital component in the
care of the severe Burn Injury patient.
7.3.5.7 Pathology services
Fresh whole blood, and regular blood serum analysis form a major part of the severe
Burn Injury care both perioperatively and during resuscitation. Good access to
pathology services is therefore essential.
44
7.3.6 Psychosocial and mental health care
7.3.6.1 Associated psychosocial issues
Burn injuries are frequently life threatening traumas which involve extreme pain,
discomfort, hospitalisation, operations, itching, pressure garments, and physical
limitations. A host of these issues have significant implications for the affected
individual and their families. Furthermore, burn care treatment can be lengthy and
painful requiring a variety of psychological and social resources for optimal recovery.
The psychosocial difficulties encountered by patients after a Burn Injury may include:
Problems managing pain, itching and discomfort
Problems with post-traumatic stress including anxiety, nightmares, flashbacks,
avoidance, emotional numbing
Mental health difficulties such as delirium, depression, anxiety
Grief and loss issues
Functional problems of mobility, and dexterity which inhibit/delay return to work
or school
Problems about medical choices and decisions
Difficulties coping with social reintegration
Social support problems eg family, partner, peer isolation etc
Body image and sexuality issues
Furthermore, patients presenting with burns injuries have higher rates of pre-morbid
psychosocial difficulties compared to the general population including substance
abuse, self harm, psychosis, relationship difficulties, impulsive risk taking and
depression. 57 These factors will impact upon the patient’s ability to effectively cope
with, and adjust to, a Burn Injury.
In addition, a study by Van Loey and Van Son in 2003 demonstrated that Depression
and Post Traumatic Distress Syndrome are common in patients with full thickness
burns injuries and can contribute to long term chronic mental illness 58
7.3.6.2 Intentional Burn Injury
In 2004 WA Health reported on the cost of Intentional Injury. Findings included, 1.2%
of hospitalisations for injuries inflicted by another was a Burn Injury. However, 12.8%
of the total cost of hospitalisations for injuries inflicted by another was attributed to
Burn Injury care. Additionally, 0.8% of hospitalisations for all self inflicted injury were
a Burn Injury. However, 4.5% of the total cost of hospitalisations for self inflicted
injury was attributed to Burn Injury care. 59
45
In 2004 nurses and other burn care team members at the RPH Telstra Burn Injury
Unit identified an increase in self-inflicted Burn Injury and related re-admissions. A
retrospective audit and clinical review over a six-year period from January 1998 to
December 2003 was conducted. 60 Of the 1239 patients admitted during this period
44 (3.5%) were admitted for self-inflicted Burn Injury. The findings of the audit were:-
There were an equal number of male and female cases; however there was a
greater proportion of females in this patient group when compared to
admissions for burns as a result of non intentional injury.
The average %TBSA for self-inflicted Burn Injury was significantly higher at
31.9% compared to 7.8% in general admissions. 61
The most common causal agent was flammable liquid and flame (47.7%), flame
(22.7%) and caustic soda (15.9%).
Socio-economic factors identified: Fifty percent of these cases occurred at
home, with 50% unemployed and 75% had a previous diagnosis of psychiatric
illness.
62% had previously been admitted to the Burn Injury service for self-harm
where burning was the self harm mechanism.
The outcomes were as follows, 20.5% (n=9) died, 20.5% (n=9) transferred to
mental health facility and over 50% discharged home.
Evidence in the reported literature has identified a lack of psychiatric care and
support after hospital discharge for deliberate self harm burns patients. Although
patient numbers were small in this case review, the high proportion of patients with a
previous diagnosis of psychiatric illness and/or a previous admission for self harm
burns injury would appear to support this view.
7.3.6.3 Strategies to manage psychosocial issues
Effective psychosocial assessment and management should be aimed at maximising
psychosocial adjustment to a Burn Injury and minimising ongoing psychological or
mental health difficulties. Assessment and management of emotional distress, pain
coping strategies, grief and bereavement, livelihood, survival and mental health
issues, and dealing with changes in body image and sexuality, are necessary in the
care of the patient with a severe Burn Injury, in order to ensure optimal compliance
with treatment and rehabilitation goals. 31
Burn Injury is one of the most common manifestations of non-accidental injury in
children. Increased awareness of child abuse and increasing expertise of burn
clinicians has enabled early identification of potential non-accidental Burn Injury.
Management of patients with suspected non-accidental Burn Injury includes hospital
admission. Hospital admission provides the opportunity for appropriate
investigations, psychiatric assessment and provision of care. Long term access to
psychological support and access to psychosocial and/or psychiatric intervention is
required to support burns patients particularly in the setting of deliberate self harm
where burning is the mechanism of self harm.
46
Nursing assessment should be provided throughout inpatient care and supported by
social workers, clinical psychology services and psychological services throughout
inpatient admission, and following discharge. These services provide ongoing
support to burns injury patients to assist them to manage post-traumatic and other
mental health symptoms, adjust to change in body image and lifestyle, relationship
difficulties and return to work/school programmes. 31
Mental health personnel are integral members of the burn team. They provide mental
health care to severe burn patients during all phases of the continuum of care.
Components of mental health care will include:
Psychiatric assessment
Risk assessment for self-harm or violence
Risk assessment for substance abuse
Prescription of psychotropic medication
Implementation of the Mental Health Act 1990 where applicable
Use of a range of therapeutic psychological techniques for patients and families
Long term access to psychosocial/psychiatric support
Recommendation 6:
Develop clinical protocols and risk assessment tools to assess mental health across
the continuum of care to ensure timely psychosocial intervention; with specific focus
on non accidental Burn Injury.
Recommendation 6.1:
Education for health professionals should include the roles, responsibilities and
requirements by health professionals in the setting where non accidental Burn Injury
is suspected in children.
Recommendation 6.2:
Burns Services should include a dedicated clinical psychology role to provide
specialist mental health services for Burn Injury patients.
47
7.3.7 Ambulatory Care Strategies
The multi-disciplinary Burn Injury care team is responsible for arranging the
ambulatory care of Burn Injury patients after discharge from in-patient services.
The increase in survival of patients with severe Burn Injury and the growing trend of
management of non-severe Burn Injury without hospitalisation has resulted in the
development of dedicated ambulatory burn care clinics, providing the link between
inpatient care and rehabilitation. It is envisaged that the volume of burn activity
managed on an ambulatory basis will continue to increase. An ambulatory burn clinic
may provide:
Assessment and dressing of minor and non-severe burns
Rehabilitation interventions
Follow-up burn dressing and skin graft management for patients after discharge
Coordination of rehabilitation in the home (RITH) and, or ‘local’ therapist input
Long-term scar management and symptom control after discharge
Patient and family teaching and support
Advisory service to other hospitals, health care professionals and community
Patients with a burn who require surgery, with interim burn care until the day of
surgery31
Ongoing complication risk management and treatment
In metropolitan WA, Burn Injury patients have access to outpatient wound care and
‘hospital-in-the-home’ services that provide all Burn Injury care post inpatient
discharge.
7.3.7.1 Rehabilitation
Rehabilitation commences as soon as the patient is injured. Specialised rehabilitation
input is required upon admission to the Burn Injury Unit or the Intensive Care Unit.
Rehabilitation aims to assist the patient through recovery from injury, and to optimise
their level of functional ability and social reintegration. Nurses provide holistic care
and are integral to patient care from point of admission through to rehabilitation and
ambulatory care.
Step-down facilities that are linked to acute services achieve a seamless continuum
of care by allowing patients with Burn Injury to participate in self-care activities,
prepare for discharge and enable their significant others and carers to participate in
their programme of care. Availability of such facilities reduces length of stay in acute
care facilities and builds patient confidence and independence in a supported care
environment prior to discharge from hospital. Provision of an environment that
encourages autonomy and independence for burn patients is an important part of
facilitating return to function by avoiding the prolonged dependency that extended
hospitalisation can foster.
Rehabilitation medicine provides assessment, consultation and follow-up
management of the significant disability suffered by patients with a severe Burn
Injury. The rehabilitation process is carried out in conjunction with allied health
services.
When patients return to the community, normal activities and work Burn Injury Units
should work closely with community outreach programmes. Utilising e-health
48
technology is an efficient and cost effect method of supporting community outreach
programmes throughout WA.
It is vital to give the patients equitable care by the multidisciplinary team. Developing
a network across healthcare services in the state will combine best practice and
increase early discharge back into the community. 62
Recommendation 7:
Develop programmes to assist patient integration back into the community including:
‘Medihotel’ type accommodation for step-down from tertiary care should be
available in metropolitan and rural and remote areas
Community Rehabilitation and follow up that includes education for children and
access to non- government community resources
‘Rehabilitation in the Home’ (RITH) for moderate and severe burn injured
patients
Planning for reconstruction procedures
Recreational therapy
Return to work/school planning
Psychological individual or group counselling
Linking with chronic injury support groups
7.4 Workforce education and training

Education is required across the continuum of care from prevention through to
rehabilitation. Programmes should be tailored to meet all needs from community to
specialists training at tertiary level for the workforce of the WA State Burn Services.
49
7.4.1 Pre tertiary hospital care
Education and training of clinicians outside of specialist burn units is required to
ensure a collaborative approach with specialist advice for the treatment and
management of burn injured patients. This will require the development and
implementation of clinical protocols which reflect best evidence. This will ensure
patients receive optimal care closer to home through a collaborative team under the
guidance of specialist consultation.
Further development of web-based education programmes would improve
accessibility and enhance knowledge for all personnel with interests in prevention
and management of Burn Injury. Disaster preparedness and response training should
be provided for all pre-hospital personnel, and emergency and critical care areas in
hospitals. This training should include immediate treatment and management of burn
patients in multi-casualty events.
A study conducted at the Paediatric Burns Services from 2005 to 2008 on infants
less than 6 months of age found no infants had received adequate first aid from
parents or carers. 63 Education in the community, child health centres, schools and
playgroups may target parents and carers regarding appropriate first aid.
It is estimated that of the approximate 200 patients in adult or paediatric admitted to a
tertiary WA State Burn Services facility each year, about 70 paediatrics and 100
adults would require surgical intervention and resuscitation, while the remaining 130
paediatrics and 150 adults would require resuscitation and/or conservative wound
management only. Therefore, 130 paediatrics and 150 adults could be treated
remotely with protocols, education, and e-health programmes.
Royal Perth Hospital coordinates a Burn Management Programme to staff in rural
and regional hospitals. This is provided by a visiting multidisciplinary team over a one
day course. Similarly, a one day targeted course for rural General Practitioners is
available upon request. WA State Burn Services should also provide train-the-trainer
education on emergency burn care and inpatient treatment, to pre-hospital staff. 32 In
addition, Wounds West Module E-learning programme should be accessible by all
health professions across WA to ensure consistent assessment and care of burn
injured patients.
50
Recommendation 8:
Develop and provide education packages and training for the appropriate transfers of
patients to regional, rural and remote facilities who will have first contact with burn
injured patients.
Recommendation 8.1:
Increase access to web-based training and e-health modalities to improve training
and education programmes for clinical workforce. This will require increased
resources to improve state wide e-health services with links to Wounds West.
Recommendation 8.2:
Provide disaster preparation education which includes training on treatment of Burn
Injury for all pre-hospital and hospital health care providers in emergency and critical
care areas.
7.4.2 Specialist tertiary services education and training

Burn nursing is recognised as a nursing specialty. Nursing staff constitute the largest
component of the multidisciplinary Burn Injury team and are responsible for patient
safety and well-being 24-hours a day. Therefore, coordination of the multidisciplinary
burn team is usually a nursing responsibility. Since 2004 RPH has held a three day
course in Advanced Burn Nursing. The Australian New Zealand Burns Association
Emergency Management of Severe Burns course is an integral part of emergency
burn education. Registered nurses, senior burn therapists and senior medical officers
should be supported to complete this course within 12 months of their appointment to
a Burn Injury Unit.
On-going professional development is required for nursing and allied health staff
including where appropriate, the acquisition of tertiary qualifications. Appropriate
training and professional development learning opportunities should be made
available through Telehealth support for the clinical workforce in rural and remote
areas. In addition, collaboration with Australian Universities is needed for tertiary
level qualification.
The University of Adelaide currently provides a Post Graduate Diploma in Nursing
Science (Burns Nursing) course which can be completed externally. However burns
specific clinical or course work postgraduate programmes are extremely limited in
Australian Universities. Furthermore, due to the limited positions available for
specialised burn therapists in Australia, postgraduate courses in this area are not
offered in Australia for nurses.
With respect to the medical workforce, there are current discussions with UWA for
establishment of a postgraduate burn therapy module, in 2009, through the faculty of
the Centre for Musculoskeletal Studies, Department of Surgery. The lack of
programmes for higher education for burn specialists is due to the small number of
available clinical positions in a highly specialised workforce. This contributes to a
high turn over of specialised burn therapists creating a significant issue for retention
of specialist burns clinicians. In addition, individuals with higher degrees for
dieticians, social workers and psychologists lack specific postgraduate training in
51
burns care.30 Currently psychiatrists and psychologists have limited access to training
opportunities. Mental health staff shortages are being experienced globally and
current literature recommends advances in higher education to address the issue. 64
Recommendation 9:
Establish stronger partnerships between the Department of Health WA and
Australian Universities through clinical workforce initiatives to establish curriculum for
short modules or multi-disciplinary postgraduate programmes that focus specifically
on burns injury.
Recommendation 9.1:
Provide training and professional development learning opportunities through
Telehealth support for nurses and allied health professionals in rural and remote
areas.
7.4.3 Mass casualty care and stabilisation

Burn Injury is one of the most common injuries to occur during mass casualty
events. 65 Therefore, during the planning and response to a disaster, trained burns
specialists should be involved. To facilitate this process, involved burn specialists
must have disaster management training, and understand their responsibilities in an
emergency situation.30 This training should be inclusive of general disease
preparedness for mass casualty and specific Burn Injury. ‘Major Incident Medical
Management Support (MIMMS)’ training is the internationally accredited course
offered to both government and non-government agencies in Western Australia.
A disaster plan is required for the triage and treatment of burns patients in an event
of a mass casualty incident. Department of Health (WA) representatives and the
Head of Department for the Burn Injury Units should revise and modify the disaster
plan to ensure consistency with state and national plans.
Registration of burns care specialists on the AUSMAT register should be encouraged
to ensure that appropriate personnel will be sourced to support local workforce in all
states in the event of a mass casualty event with multiple burn injuries, where a
national response is required. These personnel should receive appropriate disaster
training.
52
Recommendation 10:
Provide individual training of all staff within Burn Injury Units in disaster preparedness
and disaster response training.
Recommendation 10.1:
Regular contact by the Burn Injury Units should be made with the State Health
Coordinator (Disaster) through provision of information to the Australian and New
Zealand Burn Association National Burns Registry and State Health Disaster
Committees.
7.5 Outcomes
7.5.1 Clinical Review
Research and training are pivotal to the provision of excellent services. All new
methods and new technologies require implementation within a framework of ethics,
clinical protocol, review and audit. Changes need to be made so that tertiary centres
are research driven to provide an evidence-based service of excellence. This
requires the recognition that workforce must be skilled in areas of service, research
and training. Other staff members from complementary disciplines must also support
staff to counter the developing workforce shortages. Currently the Burns Clinical
Outcome Research Project (BCORP) coordinated by RPH is working to evaluate
advances in treatments by establishing a new set of standards to measure treatment
success in burns. Other research is focussing on physiotherapy, nutrition, artificial
skin substitutes and surgical intervention of serious burn patients.
7.5.2 Quality Improvement and Research
With the appropriate infrastructure for communication, state wide protocols should be
developed to guide management of non-surgical cases. These protocols will ensure
non-surgical patients are treated as close to home as possible. The protocols will
only be cost effective if management is truly collaborative. A major issue is the lack of
experience in both assessment and appropriate Burn Injury management state wide.
This lack of experience leads to late referral, increased infection, prolonged healing
and poor scar outcomes. However with the implementation of appropriate protocols,
outcomes based education, and communication the benefits will improve service
delivery and immediate care and reduce patient transfer errors.
To ensure improved quality of patient care within Burn Injury Units, internal and
external audits should be carried out regularly. Similarly, maintaining hospital
accreditation and suitable verification is particularly important. 30
Tertiary level centres are the source of evidence-based best practice and excellence
in care. Research regarding clinical outcome with feedback loops into initial care
protocols is essential to continually develop the evidence base, and monitor
outcomes and treatment modalities within a research framework to provide sound
rigor. This offers the most effective method of the dissemination of results through
translational research.
A retrospective, observational study between 1992-02 was conducted by WA Health
to compare treatment and outcomes between Aboriginal and non-Aboriginal children
and adults in WA. Although a greater proportion of Aboriginal people sustained major
53
burn injuries, similar levels of service and outcomes were found compared to non-
Aboriginal people. Without this research and given the trends seen for chronic
disease the assumption would be that outcomes for Aboriginal people are poorer.
More research is warranted in burn care, ranging from culturally and environmentally
appropriate prevention through to assessment of outcomes. 66 Researchers should
therefore be considered an essential member of the multidisciplinary team
7.5.3 Information and Care Management System
An information management system is required to improve coordinated care. A
Burns Information Management System has been demonstrated to be effective in
proof of concept testing. It has been piloted with government funding at RPH and
with the view to links with PMH. Further investment and funding to finalise the
production module to support on going state-wide (web-based) development and
implementation of this management system is required
Recommendation 11:
Support the current tertiary centres to develop as a virtually united centre of
excellence that makes a major contribution to the international literature for Burn
Injury management.
Recommendation 12:
Further investment and funding for the ongoing innovation and development of the
WA Burns Service Burns Information Management System at the Adult & Paediatric
Burns Services is required.
54
Glossary
≈ Approximate
ANZBA Australian and New Zealand Burn Association
BCORP Burns Clinical Outcome Research Project
ED Emergency Department
FESA Fire and Emergency Services Authority
MIMMS Major Incident Medical Management Support
PCA Patient Controlled Intravenous Analgesia
%TBSA Percentage of total body surface area
RPH Royal Perth Hospital
PMH Princess Margaret Hospital
SES Socioeconomic status
AFPA The Australian Fire Protection Association
JAFFA The Juvenile and Family Fire Awareness Programme
UWA The University of WA
WA Western Australia
55
Appendices
Appendix A: Aboriginal health impact statement
Model of Care for Burn Injury

1. Will this policy, programme or strategy significantly affect the health of
Aboriginal people?
If so, how:
2. Is this policy, programme or strategy likely to lead to a change in the nature or
level of resources of health services available for Aboriginal Health?
If so, specify:
3. Have all items of the checklist been reviewed and answered?
Statement
The health needs and interests of Aboriginal people have been considered, and
where relevant, incorporated and appropriately addressed in the development of this
health policy, programme or strategy.
Head of Unit name: Dr Simon Towler
Unit name: Health Policy and Clinical Reform Division
56
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disease, 2000. Geneva: World Health Organisation; 2002.
3 Peck M, Kruger, G, van der Merwe, A, Godakumbura, W, & Ahuja R. Burns
and fires from non-electric domestic appliances in low and middle income
countries Part I. The scope of the problem. Burns 2008;34(3):303-11.
4 Mock C, Peck M, Peden, M, & Krug E. A WHO plan for burn prevention and
care. Geneva: World Health Organisation; 2008.
5 National Public Health Partnership (NHPH). The National Injury Prevention
and Safety Promotion Plan 2004-2014. Canberra; 2004.
6 Epidemiology Branch. Public Health Division DoHWA. Australian Bureau of
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60
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Injury & Trauma

Professor Fiona Wood

Figure 1. WA Burn Injury definition

BURN INJURY ASSESSMENT

MINOR MODERATE SEVERE

Figure 2. Triangle of Care

What the patient needs to recover

5.3 Western Australia

Age-standardised per 100,000 population

5.3.2 Trends by age

300 Male searations 160

Source: WA Hospital Morbidity Data System

Rate per 100,000 persons

Source: WA Hospital Morbidity Data System

Table 1. Proportions of hospitalisations for Burn Injury by cause, non

Non-Aboriginal (%) Aboriginal (%)

Figure 6. Age-standardised hospital separations with a principal diagnosis of

Age-standardised per 100,000 population

Age-standardised per 100,000 population

5.3.5 Types of Burn Injury

0–4 5–24 25–64 65+ Total

Promotive Preventive Curative Rehabilitative

Education Assess and Education Education

A holistic multidisciplinary approach has been taken in developing the framework

Department of Health Service Agreements with non government organisations for

BURN INJURY ASSESSMENT

Regional/Rural/Remote E-health Outreach to non-specialist centres

Conservative Wound Conservative Wound Surgical Repair

Conservative path Multidisciplinary inpatient’ care

Facilitated early discharge by:

7.3.4.3 Respiratory complications

7.3.5.2 Wound management

7.4 Workforce education and training

7.4.2 Specialist tertiary services education and training

7.4.3 Mass casualty care and stabilisation

ANZBA Australian and New Zealand Burn Association

BCORP Burns Clinical Outcome Research Project

FESA Fire and Emergency Services Authority

MIMMS Major Incident Medical Management Support

PCA Patient Controlled Intravenous Analgesia

%TBSA Percentage of total body surface area

RPH Royal Perth Hospital

PMH Princess Margaret Hospital

SES Socioeconomic status

AFPA The Australian Fire Protection Association

JAFFA The Juvenile and Family Fire Awareness Programme

UWA The University of WA

Model of Care for Burn Injury

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